Appeals and Grievances Specialist

About Medica

Medica is a nonprofit health insurance provider serving over a million members across Minnesota, Nebraska, Wisconsin, Missouri, and additional regions. The organization specializes in delivering customized healthcare experiences and fosters close collaborations with providers to ensure members receive truly compassionate care. Medica values accountability, data-informed decision-making, continuous learning, and teamwork, aiming to create a connected care community where quality and coordination are standard, and every member is respected and valued.

Primary Responsibilities

• Manage the entire process of appeals and grievances, addressing complaints and disputes raised by members, providers, or clients regarding claims, coverage, benefits, or service issues.
• Conduct detailed investigations to collect pertinent information, evaluate complaint legitimacy, and formulate fair resolutions.
• Handle pre-service authorizations, concurrent and retrospective medical necessity reviews, and resolve intricate provider claim disagreements.
• Ensure all appeals and grievance activities are processed accurately and within designated timeframes, adhering to policies and relevant regulations.
• Document thoroughly all complaints, investigations, decisions, and outcomes within the organization's systems.

• Stay compliant with federal, state, and organizational standards, including CMS, DHCS, DMHC, NCQA, and others.
• Prepare and submit reports for leadership and regulatory bodies, highlighting trends, root causes, and potential concerns.
• Participate in internal and external audits, inter-rater reliability checks, and ongoing compliance monitoring.
• Track performance indicators and turnaround times to ensure contractual and legal adherence.

• Act as the main liaison for members, providers, and internal teams during the grievance and appeals processes.
• Communicate decisions clearly and confidentially, offering guidance on appeal rights and procedures.
• Collaborate with clinical, operational, and customer service departments to resolve issues and improve stakeholder experiences.
• Advocate for fair, impartial dispute resolutions while maintaining professionalism and objectivity.

• Analyze data related to grievances and appeals to identify trends, recurring problems, and workflow inefficiencies.
• Propose and implement corrective measures to minimize future complaints and enhance service quality.
• Ensure data integrity and accuracy in grievance and appeals databases and support quality improvement initiatives through reporting and feedback.

Required Qualifications

• Bachelor's degree or a comparable combination of education and experience in a related field.
• Minimum of three years of work experience post-degree.

Preferred Qualifications

• At least three years of relevant experience in appeals and grievances, healthcare operations, insurance, or similar areas.

Skills and Abilities

• Exceptional written and verbal communication capabilities.
• Strong analytical and problem-solving skills to ensure effective case processing.
• Capacity to collaborate effectively with a diverse range of personnel, including members and providers.
• Proven ability to manage multiple priorities efficiently in a dynamic environment.
• Proficiency in Microsoft Office applications such as Word, Excel, and Outlook.

Additional Information

This role is fully remote; candidates must reside in a state where Medica is registered as an employer (AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI). The annual salary grade ranges from $45,900 to $78,600, with typical hiring salaries between $45,900 and $68,775, dependent on education, experience, certifications, role responsibility, internal equity, and market data. Benefits include competitive medical, dental, vision coverage, paid time off, holidays, volunteer time off, 401K, caregiver services, and more. Employment is contingent upon eligibility to work legally in the U.S., as no visa sponsorship is provided. Medica practices Equal Employment Opportunity, considering candidates based on merit irrespective of protected characteristics.